Beuerle, John - POWERPOINT Emergency Department...

8/30/2011

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Emergency Department Misadventures(Cases You Don’t Want to Miss)

John Beuerle, M.D., M.S.

8/30/2011

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I’m brilliant.You’re the only one not looking at the

screen.

8/30/2011

3

These guys worship me.I worship him.

I can’t hear a thing.

I can’t believe I forgot to bring

my stethescope.

I gotta pee.

If I don’t eat something soon, I’m gonna pass out.

If my purse goes missing, I’m calling security.

I’m here for knee pain.

This coffee tastes horrible. That’s a urine sample.

8/30/2011

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What’s next?Geriatric Medicine

NASCAR pit crew

Sports Medicine

Anesthesiology

Tarot Card Reader

Neurology

Neurosurgery

Batman

Orthopedics

Pediatrics

Family Practice

Physical Rehabilitation

Emergency Medicine

Surgery

OB/GYN

Veterinary Medicine

Just try not . . .

to kill anyone!

Let’s begin.

8/30/2011

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Case # 1: Lights on. Nobody home.

• 3 y.o. female

• Lights on. Nobody home.• Blank stare. Rotary nystagmus.


• Initial treatment?• Labs?

• CBC: normal• BMP: normal• UA: normal• Tylenol / Salicylate:

negative

• CT head?normal

• Tox screen:Positive for PCP


• What now?– Child Protective Services?– PICU?

– Strangle theparents with your bare hands?

Case # 2: Tequila Jane

• 16 y.o. female, arrives by EMS• HPI:

– Found unresponsive at home.– Empty bottle of tequila in room. – Family reports patient

“may have been drinking.”– Family called 911.

• PMHx: none• SocHx: Nonsmoker, occasional EtOH,

No illicit drug use• FmHx: HTN, asthma, hyperlipidemia

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• Physical Exam:– Strong odor of alcohol to breath.– Moans / withdraws to deep painful stimuli– BP 96/68, HR 56, RR 12, Temp 98 F, 96%

on room air– PERRL– Small amount of emesis in oropharynx.– No external signs of trauma.


• Initial management?– Airway management

(suction)– Check fingerstick glucose !!!– EtOH level, tox screen

– CBC, CMP, UA, HCG? – EKG, CXR, CT head?– What else??

Normal !!

Case # 3: Whiskey Joe

• 54 y.o. self-proclaimed concert pianist

• Wife called 911 because patient was “drunker than usual”.

• PMHx: HTN, DM, a-fib, and . . . wife reports: “He’s a pathological liar.”

• “He can’t even play a kazoo.”

?Case # 3: Whiskey Joe

• Physical Exam– Dissheveled.– Strong odor of alcohol

. . . and feet.– No external signs of trauma.– Mutters incoherently.– Kazoo found in back pocket.

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• Initial management?– Airway management – Check fingerstick glucose !!!– EtOH level, tox screen– CBC, CMP– HCG (rule-out ectopic pregnancy) – EKG, CXR, CT head?

Normal !!


10.411.4

34.8298

137

6.2

98

25

13

0.9118

96

32

42

0.6

6.7

3.6UA: nml

Tox screen: negativeBAL 210

54 y.o. male with altered mental status

Vitals: 82/54, HR 50, RR 12, Temp 98.7 F

Urine hcg: positive !!!2.423.2

45.6

8/30/2011

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CT head (Just kidding.)

• 62 y.o. female pig• Brought to ED by ambulance.• Found down in trough.• Suicide note paper-clipped to her tail.

Case # 4: The Actress Swine Formerly Known as Miss Piggy

Kermit,

You never loved me.

Goodbye,

Piggy

8/30/2011

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Case # 4: The Actress Swine Formerly Known as Miss Piggy

8.210.4

32.7289

134

4.3

97

25

18

0.8108

26

38

42

0.6

6.8

4.1

Tox screen: BAL 82

HCG: neg

62 y.o. suicidal pig with altered mental status

Vitals: 70/42, HR 160, RR 14, Temp 99 F

Lightweight !!(Even for a pig.)

Positive for bacon !!

We need you in Room 8!!

STAT !!!


10.212.4

36.7301

136

4.2

97

25

11

0.8211

26

38

42

0.6

6.8

4.1UA: nml


HCG: neg

16 y.o. female with altered mental status


8/30/2011

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X-ray: Head CT:


• Vitals: 54/32, HR 32, RR 12, Temp 98 F• Tylenol / salicylate levels: negative• Repeat EKG

8/30/2011

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We need you in Room 4!!

STAT !!!


I wanna sandwich.

Vitals: 74/50, HR 48

What’s wrong with these patients?!!• Just plain drunk• Faking it• Conversion Disorder• Minding their own business . . .

when all of a sudden . . . TWO DUDES jumped out of the bushes and gave them hypotension and cardiac arrhythmias!!

• Could they have overdosed?!!• If so, on what?!!

• What commonly prescribed medications are cardiotoxic?– Digoxin– β-blockers– Calcium channel blockers– Clonidine

8/30/2011

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How can we tell the difference?– Check a level.– Ask the family. Check the medicines.

Patient’s meds include . . . . . . atenolol !!!

. . . and enalapril !!. . . and digoxin !!

. . . and clonidine !!. . . and Preparation H !!!

Cardiotoxic Drug Overdose

• How can we tell the difference?– Preparation H

• Usually not cardiotoxic, except in extremely large doses.

• How can we tell the difference?– Digoxin

(myocardial cell)

Digoxin

K+

Na+

Ca++

Ca++

Na+

More Ca++ inside = Improved Contractility

1


Digoxin

K+

Na+

Ca++

Ca++

Na+

1Acute toxicity:

hyperkalemia

8/30/2011

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– Large Volume of Distribution

• In acute poisoning, a low level is not necessarily reassuring.

• In symptomatic patients, do not wait for a level to treat!!

Total amount of drug in the body

Blood plasma concentration of drug VD =

Digoxin

• Symptoms of acute toxicity:– First 6 hours: GI symptoms– At 3-4 hours: cardiac effects

• bradycardia, PVCs• AV node effects:

– atrial fibrillation / flutter– high degree AV blocks

Digoxin

DigoxinThe “Salvador Dali sign” on EKG correlates with digoxin use, not necessarily with digoxin toxicity. How can we tell the difference?

Digoxin

β-blockers

Calcium channel blockers

Clonidine


8/30/2011

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Digoxin

K+

Na+

Ca++

Ca++

Na+

1Acute toxicity:

hyperkalemia

How can we tell the difference?

Digoxin

β-blockers


Clonidine

bradycardia +


K+

β-blocker sites of action

blockade of pulmonary beta 2 receptors causes bronchoconstriction

blockade of renal beta 1 receptors blocks release of renin causes decreased blood pressure

Blockade of beta receptors in the CNS reduces performance anxiety

blockade of smooth muscle beta 2 receptors causes vasoconstriction and GI effects

blockade of beta receptors impairs glycogenolysis and gluconeogenesis, causing hypoglycemia


Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose


8/30/2011

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Calcium Channel Blocker sites of action

Peripheral vasodilatation

• Decreased chronotropy (rate)

• Decreased dromotropy (conduction)

• Decreased inotropy (squeeze)

• Decreased FFA utilization

Decreased insulin release from the pancreas, causing hyperglycemia


Digoxin

β-blockers

Ca++-channel blockers

Clonidine

bradycardia +

bradycardia +

K+

Glucose


bradycardia + Glucose

Glucose


Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



8/30/2011

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Clonidine

“Clon” receptor “dine” receptor+

Clonidine

• Centrally acting• Alpha-2 agonist

– Decreased HR– Decreased BP– Decreased RR– Vasodilatation

• No heart blocks• Opioid-like effects

– Altered Mental Status– Pinpoint pupils

• May be reversed with naloxone

Inhibits sympathetic outflow


Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +

Why do we care?

• “We don’t. It’s Miller time!!”

• The treatment is different !!!

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How is the treatment different?• ABC’s• Consider activated charcoal and whole bowel

irrigation.• Clonidine toxicity: naloxone, fluids, vasopressors• Digoxin toxicity

– Digibind (Digoxin specific Fab fragments)• Indications:

– K+ ≥ 5 mEq/L– Digoxin level ≥ 10 ng/mL– Ventricular arrhythmias– Hemodynamic instability

• Serum digoxin level may appear to increase as drug is removed from within cells.

How is the treatment different?

• β-blocker toxicity– Atropine, cardiac pacing– Glucagon (5 mg IV, then 5 mg/hour IV)– Calcium

• Ca-gluconate 3 amps IV or CaCl 1 amp via central line

Ca++


• β-blocker toxicity– Atropine, cardiac pacing– Glucagon (5 mg IV, then 5 mg/hour IV)– Calcium


– Hemodialysis (for atenolol only)

8/30/2011

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• Ca++-channel blocker toxicity– High mortality !!! Why??

Atropine

Ca++


• Ca++-channel blocker toxicity– High mortality !!! – Atropine– Glucagon– Calcium


– Hemodialysis?(Ineffective.)

Is there no hope??!

Treatment: Calcium ChannelBlocker Toxicity

• High-dose insulin therapy– 1 unit/kg IV, then 0.5 units/kg/hour IV– Ten-fold higher dose than used for DKA !!

Calcium Channel Blocker sites of action

Peripheral vasodilatation

• Decreased chronotropy (rate)

• Decreased dromotropy (conduction)

• Decreased inotropy (squeeze)

• Decreased FFA utilization

Decreased insulin release from the pancreas, causing hyperglycemia

8/30/2011

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Treatment: Calcium ChannelBlocker Toxicity

• High-dose insulin therapy– 1 unit/kg IV, then 0.5 units/kg/hour IV– Ten-fold higher dose than used for DKA !!– Restores insulin supply to the body.– Provides glucose to starved myocardial cells.– Reduces lactic acidosis.– Insulin itself has inotropic properties.– Watch for hypoglycemia:

• Check fingerstick every 30 minutes.• BG < 400, give D50 or D25 @ 0.5 grams/kg/hour IV

High Dose Insulin Therapy for Calcium Channel Blocker Toxicity

• Animal studies: markedly reduced mortality

• Human clinical case reports:

• Improved hemodynamic stability

• Reduced need for vasopressors

• Improved survival in critically ill patients


10.212.4

36.7301

136

4.2

97

25

11

0.8211

26

38

42

0.6

6.8

4.1UA: nml


HCG: neg




8/30/2011

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Case # 2: Tequila Jane Case # 2: Tequila Jane

10.212.4

36.7301

136

4.2

97

25

11

0.8211

26

38

42

0.6

6.8

4.1UA: nml


HCG: neg




Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +


10.411.4

34.8298

137

6.2

98

25

13

0.9118

96

32

42

0.6

6.7

3.6UA: nml


54 y.o. male with altered mental status

Vitals: 82/54, HR 48, RR 14, Temp 98.7 F

INR 2.4

8/30/2011

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Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +

But what about the pig?Case # 4: The Actress Swine Formerly

Known as Miss Piggy

8.210.4

32.7289

134

4.3

97

25

18

0.8108

26

38

42

0.6

6.8

4.1

Tox screen: BAL 82

HCG: neg

62 y.o. female pig with altered mental status


Lightweight !!(Even for a pig.)

Positive for bacon !!

8/30/2011

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Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +

Tachycardia I

aVF

Right axis deviation

8/30/2011

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Large R wave in aVR Wide complex QRS


Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +

Tricyclic antidepressant overdoseaVR

Tachycardia

Right axis deviation

Large R wave in aVR

PR, QRS, or QT prolongation

8/30/2011

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Tricyclic Antidepressant Overdose•

QRS widening• associated with development of seizures and

arrhythmias• can be used to assess severity of TCA toxicity• QRS < 100 ms: unlikely to develop seizures and

arrhythmias• QRS > 100 ms:

• 34% of patients develop seizures• 14% of patients develop serious arrhythmias

• QRS > 160 ms: 50% of patients develop ventriculararrhythmias

Tricyclic Antidepressant Overdose

• A large R wave in aVR is a highly sensitive screening tool for TCA toxicity.

• Amplitude of R wave in aVR may be even more predictive of seizure and arrhythmia than QRS prolongation.• Liebelt, et al: R wave > 3 mm in aVR was 81% sensitive

and 73% specific for the development of seizures and arrhythmias


• Treatment of TCA Overdose:• Airway management• Activated charcoal• Sodium bicarbonate

• Indications: • QRS widening, hypotension, dysrhythmias, seizures

• 1-2 amps IV bolus, then• 3 amps in 1 Liter D5W, infuse at 250 mL/hour IV

• Treat seizures with benzodiazepines• Treat hypotension with IV fluids and Levophed• Dopamine is usually ineffective

(TCAs deplete NE stores by blocking re-uptake.)


• Use of anti-arrhythmic agents

• Avoid class Ia, Ic, II, and III

• Lidocaine (Ib), magnesium, and Dilantin may be useful

8/30/2011

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• 3 y.o. female

• Lights on. Nobody home.• Blank stare. Rotary nystagmus.


• Initial treatment• Labs

• CBC: normal• BMP: normal• UA: normal• Tylenol / Salicylate:

negative

• CT head?normal

• Tox screen:Positive for PCP


• What now?– Child Protective Services– PICU

– Strangled theparents with our bare hands.

• Child recovered uneventfully in PICU.

• Parents sent to trauma center after being strangled.

• Child removed from home and sent to foster care.

Case #1: Follow-up

8/30/2011

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8 months later . . .

• Court Summons

“Hello, attorney?”


• Toxicology expert for Defense:

“This was a classic case of . . .. . . dextromethorphan overdose, not PCP intoxication.”


“The patient broke into a medicine cabinet with a lead pipe in the conservatory, and was discovered by the maid, Ms. White.”

8/30/2011

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“Dextromethorpan is present in many cough and cold medications.

“Accidental overdose inchildren is common.”


“Intentional recreational overdose in adolescents and young adults is also common.

“I’ve never touched the stuff.

“Honest.”


“An ingestion of 5-10 times the recommended dose of dextromethorphan can be toxic and induce a dissociative state, much like ketamine.”


“Oof!! Someone just hit me over the head with a wrench!”

“Trying to suppress my testimony, no doubt.”

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“The chemical structures of dextromethorphan and PCP are very similar, and may cause a false positive result for PCP on hospital toxicology screens.”


“Confirmatory testing by an outside laboratory is always recommended in cases of suspected child abuse.”


“Dextromethorphan can also induce Seratonin Syndrome in patients who are taking an SSRI.”


“Symptoms include muscle rigidity, hyperthermia, altered mental status, and hyperreflexia which is more profound in the lower extremities.”

8/30/2011

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“Agghpphcchtt!!!

“Someone just tried to strangle me with a rope!!

“Trying to suppress my testimony, no doubt.”


“Treatment for dextromethorphan overdose is mostly supportive.”


“Treatment for Seratonin Syndrome includes benzodiazepines, cooling, and for severe cases, cyproheptadine.”


“Treatment for wounds sustained by this revolverthat’s being pointed at me by Ms. Scarlett may be more extensive.”

8/30/2011

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What did we learn?

• Alcohol isn’t the only drug that can cause altered mental status.

• Be very careful with intoxicated patients.– Poor historians.– Poor judgement.– Prone to trauma.– Smelly and obnoxious = no physical exam– Delayed diagnosis of life-threatening

conditions.

What did we learn?

• Prescription medication overdoses are common.

• They are also more likely to be missed.– Often not suspected.– Most meds don’t show up on a tox screen.– Most don’t have levels to check.

What did we learn?

• Many prescription medication overdoses can be lethal.

• Many commonly prescribed medications can be cardiotoxic in overdose.– Digoxin– β-blockers– Calcium channel blockers– Clonidine– Tricyclic antidepressants


Digoxin

β-blockers


Clonidine

bradycardia +

bradycardia +

K+

Glucose



bradycardia +

Tricyclic antidepressant overdoseaVR

8/30/2011

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What did we learn?• Treatment differs depending on the drug.

– Digoxin• Digibind

– β-blockers• Atropine, pacing, glucagon, calcium

– Calcium channel blockers• Atropine, pacing, glucagon, calcium• High-dose insulin therapy

– Clonidine• Naloxone

– Tricyclic antidepressants• NaHCO3, benzodiazepines, Levophed, lidocaine

What did we learn?• Don’t jump to conclusions. • Many drugs can trigger

false positives ontoxicology screens.

• Admit to the PICU

• Notify CPS

• Reserve judgment of the parents for another day.

Thanks for listening.

Beuerle, John - POWERPOINT Emergency Department...

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Transcript of Beuerle, John - POWERPOINT Emergency Department...